5 requirements of CPC+: Comprehensiveness and coordination (function 3)

This blog is the third in a five-part series that will help you review your current CPC+ implementation. Now that we’re 2 to 3 years into the program, you can review what has and hasn’t been working for your practice with the help of these guides.

For practices considering Primary Care First, this series can also be used for preparations as you gear up for a 2021 or 2022 implementation. CPC+ was one of the models examined and was a foundation for creation of the PCF.

Missed the first couple of blogs in our CPC+ series? Review how well you’ve been meeting access and continuity (function 1) here and care management (function 2) here.

Function 3: Comprehensiveness and coordination

Function 3 dictates a higher level of coordination with specialists. Patients have a range of issues, which means they see providers who have various types and levels of expertise. While this expands the skill sets your patient can leverage, it also challenges you in your care management efforts. This requires even closer communication with a wider range of providers, some not even within your organization.

As you undoubtedly recall, CPC+ 2018 Program Year 1 was all about identification. You needed to have the data and analyze it to be able to create a plan of action. Which high-cost specialists do a large number of your patients see? Also, where do a majority of your patients go for hospitalizations and ED visits? Once you identify those hospitals and EDs you can examine the timeliness and effectiveness of notification and information transfer.

2018 Program Year 2 moved on from identification to action. Now that you know the specialists that many of your patients see, you should enact collaborative care agreements with at least two of them (although the more agreements you create, the greater the benefit for your patients). Similar to 2018 Program Year 1, you should examine and work to improve the timeliness of notification and information transfer from hospitals and EDs that see a majority of your patients.

By 2019 and beyond you should know which specialists your patients are seeing at the highest frequency and cost. Implementing an efficient workflow helps connect them most effectively. Also important is providing integrated behavioral healthcare, whether through option 1 or option 2 (more information on that below).

Behavioral health integration

It’s important to develop a plan to implement at least one option for integrating behavioral health into care from the CMS-provided menu of options. The option you choose should be based on what’s the best match for your patient population.

Option 1 is for practices that have an RN or BH specialist in-house who can provide care management. For those who do not, option 2 enables you to integrate a co-located BH professional in a primary care setting to see targeted patients through a warm handoff.

We all know that it’s not enough to merely implement these criteria; they also must be constantly examined and refined going forward. Periodically ask yourself and your care team to periodically examine which behavioral health integration you chose and why? How well is it working for your patient population and, for that matter, individual patients who may need other options?

Do you have enough patients now who need behavioral health services that it makes sense to bring an RN or BH specialist in-house? Just because you’ve already chosen an option doesn’t mean you have to stick with it as your practice, your population and your options evolve.

What’s the difference if you’re Track 2?

In addition to everything mentioned in Track 1, Track 2 includes comprehensive medication management. This is important because patients can be prescribed many different medications from many different doctors, take a mixture of over-the-counter meds and supplements, and may not be eating the right foods to maximize positive outcomes. It’s crucial for someone to look at the patient holistically…and regularly. One patient said that at this juncture, he felt as if he were just eating pills and no longer really knew what each of them was for, nor the potential side effects he should be watching for as his drug combination evolves and grows.

CMM not a side note

So how do you provide comprehensive medication management today, and how integral truly is it to your coordinated care services program and your plans going forward? Do you have an in-house pharmacist who takes the time to sit down with patients instead of just dispensing meds? Must your care team add it to the ever-growing list of things they need to discuss and manage? CMM cannot be a tack-on or side note; its impact on optimized clinical outcomes makes it a pillar to ensuring your patients reach and maintain their best-possible health, cost-effectively.

If you feel like your current CMM solution is just checking the box for CPC+ requirements and not providing real value to your patients, you should call 866.234.4974 and learn more about how RxLive can help your practice at no cost.

You also need to remember your patients aren’t living in a bubble. Are there any health-related social needs that may affect them? As a reminder, the five domains of social needs are housing instability, food insecurity, transportation needs, utility needs and interpersonal safety. CMS created a screening tool to help identify these areas of concern.

After looking at the screening tool, consider or investigate what community resources you can provide or recommend to your patients if they answer yes for any of the questions. Social/environmental issues can have a direct affect on their their ability to adhere to a health improvement plan and, thus, their optimum achievable outcomes.

One benefit of an RxLive consultation is the clinical pharmacist has time, usually 30 minutes or more, to learn more about the patient’s social needs and can help develop a medication adherence plan that addresses their individual issues. Since the appointment is over the phone or via video chat, no transportation is necessary; this removes the barrier of transportation challenges that some patients have.

Recap: Questions to ask yourself

  1. Which high-cost specialists do a large number of your patients see?
  2. Where do a majority of your patients go for hospitalizations and ED visits?
  3. Which behavioral health integration did you choose?
  4. How has it been working for your patient population?

In addition, for Track 2 practices:

  1. How do you provide comprehensive medication management?
  2. Do you feel like your patients have enough time to discuss all of their medications?
  3. Do you have a list of community resources to address health-related social needs?

Next blog: Examining the success of your patient and caregiver engagement

Now that you’re effectively communicating with other specialists, integrating behavioral health care and, if track 2, providing comprehensive medication management and addressing health-related social needs, the next step is patient and caregiver engagement. In the next CPC+ blog, we’ll discuss the importance of listening to your patients to take your practice to the next level.

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.